Knowledge and factors associated with low level of awareness of cardiovascular disease risk factors among adult diabetics attending Tororo General Hospital: a cross-sectional study

Abstract

Introduction:

Diabetic patients have a threefold risk developing cardiovascular disease complications compared to the general population. According to world health organization diabetes mellitus accounts for over 20% of cardiovascular disease related deaths. Knowledge about the risk factors of cardiovascular disease is the first step in its prevention yet there is limited data on its prevalence particularly in primary care settings. The objective of this study is to determine the level of knowledge on cardiovascular disease risk factors and the factors associated with low knowledge among diabetic patients attending the non-communicable disease clinic of Tororo general hospital.

Methods:

A facility-based cross-sectional study was conducted on 385 adult diabetic persons attending the non-communicable disease clinic at Tororo General Hospital. Semi-structured interviewer administered questionnaires coupled with the heart disease fact questionnaire were used to collect data which was analyzed and presented as descriptive and inferential statistics.

Results:

The study revealed a suboptimal level of knowledge (76.1%) about cardiovascular disease risk factors. Being female (p = 0.002), less educated (p < 0.0001), newly diagnosed with diabetes (p = 0.002) and staying more than 5 km from the hospital (p = 0.009) were associated with low knowledge of cardiovascular risk factors.

Conclusion:

This study indicated suboptimal knowledge regarding cardiovascular disease risk factors attributable to social, patient and health facility based determinants. We give the following recommendation: improving the health care providers' capacity to offer patient centered education to enhance cardiovascular disease literacy among vulnerable diabetic subgroups.

Introduction

Diabetes Mellitus (DM) is a chronic complex metabolic disorder that leads to high blood sugar levels and can cause complications in both small and large blood vessels. According to World Health Organization (WHO), the prevalence of diabetes is increasing globally, and poorly managed diabetes can lead to significant consequences such as decreased quality of life, increased mortality rates, and productivity loss (1).

Cardiovascular diseases (CVDs) are the leading cause of death worldwide claiming 17.9 million lives per year(2). Around 32% of all annual deaths were due to CVDs, and 80% of those deaths occurred in low- and middle-income nations (3). People with diabetes are at a higher risk of developing CVDs than the general population, and the mortality rate for diabetic individuals with CVDs is much higher than those without diabetes (2, 4). CVDs that can accompany diabetes include angina, heart attacks, strokes, peripheral artery disease, and congestive heart failure. In Uganda, the prevalence of DM is at 2.7% but it is predicted that by 2035, this will have risen significantly and CVDs already account for 10% of premature deaths and cause significant disability, which can negatively impact the economy (5, 6).

The risk factors of CVDs include the modifiable and non-modifiable risk factors. The modifiable risk factors such as sedentary living, unhealthy diet, alcohol misuse, diabetes, hypertension, and hyperlipidemia. Knowledge about these risk factors is crucial in preventing CVDs, but studies have shown that there is low awareness of CVD risk factors in certain populations, including those in central Uganda (5, 7, 8).

Despite the increased risk of CVDs among diabetic patients, the growing prevalence of diabetes, the unique factors involved, implications for treatment and management, and the need to improve long-term outcomes in this population, there is limited data on their knowledge of CVD, there is limited data on their knowledge of CVD risk factors, particularly in primary care settings where preventative measures can be provided through education and screening. This study therefore set out to establish the level of CVD risk factor knowledge and describe the factors associated with the levels of knowledge among diabetic patients attending the non-communicable disease (NCD) clinic at Tororo General Hospital in Eastern Uganda.

Methods

Study design, setting and population:

A cross-sectional study was done in the NCD clinic of Tororo General Hospital. This hospital is in Eastern Uganda and serves a population of about 555,574 people who largely speak Japadhola, Ateso and English. The NCD clinic runs every Monday to Friday every week running from 9am to 2pm. The NCDs clinic at the Outpatient department of Tororo General Hospital provides general care for diabetes patients and the services that can be accessed at the NCD clinic include clinical care, laboratory, imaging, and patient counselling services. The outpatient clinic is run by 1 medical officer, one clinical officer and two nurses. Approximately 200 patients seek care at the NCD clinic every month. There are 1400 registered DM patients attending the NCD clinic and at least 20 are seen on daily basis. The study included adult diabetic patients attending the NCD clinic at Tororo General Hospital. Diabetes mellitus patients who were very ill and diabetic patients who were cognitively impaired were excluded from the study.

Sample size estimation and sampling procedure

The Kish Leslie formula (Kish Leslie 1965) was used to estimate sample size for this cross-sectional study at 95% confidence interval. The estimated level of knowledge of CVD risk factors in diabetics attending NCD clinic of Tororo district was 50% since it was unknown. Therefore, the calculated sample size was 385 participants. The DM patients' register of 1400 was used as a sampling frame. The participants were selected using the systematic random sampling technique. A sampling interval of 3 calculated from the population size (N= 1400) and sample size required (n= 385) was used. The random start was determined by simple random sampling. Three numbers (1, 2 and 3) were written each on a piece of paper, folded and placed in a box and a research team member closed their eyes and randomly choose one of the three numbers. The number chosen from the box was used as the random start, signifying the first participant for the study. Using a sampling interval of every nth number (n+3), participants were selected for the study. This procedure was applied daily for the duration of the study till the sample size was attained.

Data collection

Data was collected from September to November 2023. The participants were identified on clinic days by two enrolled nurses who acted as the study's research assistants. After their consultations, informed consent was obtained and an interviewer administered questionnaire was the research assistants that could speak English, Ateso and Japhadhola to collect data from the study respondents. The questionnaire consisted of questions about the respondents' sociodemographic characteristics and those on factors associated with their level of knowledge of cardiovascular diseases risk factors among diabetic patients. Data on the knowledge about cardiovascular disease risk factors was collected using the heart disease fact questionnaire, a 25-item scale developed by Wagner et al. to measure the CVD risk knowledge of patients with diabetes. The expressions are given in the form of a complete sentence, which may be true or false, and are answered as “Yes”, “No” or “I do not know”. Each correct answer is rated as one point, while each wrong or “I do not know” answer is rated as 0 point. The total score is calculated by multiplying the number of correct answers by 4, with 100 points being the highest attainable score. Scores of 'less than 50', ‘between 51 to 70' and the total score is calculated by multiplying the number of correct answers by 4, with 100 points being the highest attainable score. Scores of ‘less than 50’, ‘between 51 to 70’ and ‘more than 70’ were rated as ‘poor’, ‘moderate’ and ‘good’ respectively (9). Suboptimal knowledge/low knowledge is a score in heart disease fact questionnaire of less 70% conditions (10, 11).

Data analysis:

After all the data was collected, it was coded and entered in an MS Excel spreadsheet and exported into the Statistical Package for Social Scientists version 23 software (SPSS, IBM Corporation, Armonk, NY, USA) for analysis. Descriptive statistics were computed for the patienťs dependent and independent variables. Univariate and bivariate tests were run to determine the association between the knowledge on cardiovascular disease risk factors and the independent variables. A p-value of < 0.20 was used to determine the inclusion of independent variables into the multivariate model while statistical significance was noted for variables with a p-value of p< 0.05. A multivariate binary logistic regression analysis was conducted to control for possible confounding variables and to compute the adjusted prevalence ratios for the explanatory variable. Results are reported as adjusted prevalence ratios and presented in tables and graphs as frequencies and percentages.

Ethical consideration:

Approval from the Makerere University College of Health Sciences School of Medicine Research and Ethics Committee (Mak SOMREC-2023–565). Administrative clearance to carry out the study was obtained from the management of Tororo General Hospital. Consent from the patients with detailed explanations of the aim of the study were communicated to them and they were made to understand that a decision to participate or not was at their own discretion.

Results

Table 1 shows the distribution of the respondents by their socio demographic characteristics. The study comprised of 385 participants with a response rate of 100%. Majority of the participants were married 312 (81%), female 239 (62.1%) and between 45–65 years old 189 (49.1%). One third (130/385) of the study participants had attained primary level education. Nearly 71% (275/385) of the study participants resided in rural settings and 282 (73.3%) earned less than UGX. 250,000 monthly. Nearly two-thirds (293/385) of the participants had suboptimal levels of knowledge regarding CVD risk factors. Majority of the study participants had type 2 diabetes (285/385) (74%) as CVD risk factor. Health facilities were reported as the leading source of information about diabetes mellitus by 293 (76.1%) while almost one third of the participants had been living with diabetes for between 1 to 5 years 147 (38.2%). Nearly all the respondents visited the hospital regularly 361 (93.8%) and more than a half stayed more than 5km away from hospital 205 (53.2%). Table 2 shows the respondents’ knowledge about cardiovascular risk factors. The highest knowledge scores were noted with respondents knowing smoking as a risk factor for cardiovascular disease (85.5%) and hypertension (72.9%). Remarkably low knowledge scores were noted with diet (30.9%), exercise (30.9%), and cholesterol (19%). Bivariate analysis of the study variables revealed that being female, having low levels of education, earning more than 500,001 shillings and staying in an urban residence were significantly associated with having suboptimal knowledge about CVD risk factors. Furthermore, one's duration with diabetes and the distance they lived away from hospital were also significantly associated with suboptimal levels of knowledge about the CVD risk factors. Being female was linked to being more likely (aPR= 1.27, 95% CI 1.61 – 5.43; p < 0.001) to have suboptimal knowledge about CVD risk factors. Having no formal and/or primary education was associated with being more likely (aPR= 1.46, 95% CI 1.26 – 1.70; p < 0.001) to have suboptimal knowledge about CVD risk factors. A monthly earning of more than 500,001 shillings was associated with being less likely (aPR= 0.47, 95% CI 0.31 – 0.71; p < 0.001) to have suboptimal knowledge about CVD risk factors. Respondents who stayed in urban residences were less likely (aPR= 0.63, 95% CI 0.48 – 0.82; p < 0.001) to have suboptimal knowledge about CVD risk factors. Being recently diagnosed with diabetes was associated with being more likely (aPR= 1.38, 95% CI 1.07 – 1.79; p= 0.015) to have suboptimal knowledge about CVD risk factors. Study participants who stayed more than 5km from the hospital were more likely (aPR= 1.20, 95% CI 1.06 – 1.35; p= 0.003) to have suboptimal knowledge about CVD risk factors. Table 3 shows the multivariate analysis of factors associated with knowledge about cardiovascular risk factors among the diabetic patients. The multivariate logistic regression analysis identified the following statistically significant correlates of suboptimal knowledge about CVD risk factors: being female, having a low level of education, being recently diagnosed with diabetes (less than a year and between half a year to one year) and staying at a distance more than 5 km from the hospital. Female respondents (aPR = 1.21, 95% CI 1.08 – 1.37; p = 0.002) were more likely to have suboptimal knowledge about the CVD risk factors as compared to the males. Study respondents who had a low level of education (aPR 1.44, 95% CI 1.24 – 1.66; p < 0.001) were more likely to have suboptimal knowledge about CVD risk factors compared to those who had a higher education. Furthermore, respondents that had been diagnosed with diabetes for less than half a year (aPR 1.47, 95% CI 1.15 – 1.87; p= 0.002) and those between half a year to one year (aPR 1.33, 95% CI 1.07 – 1.67; p= 0.012) were more likely have suboptimal CVD risk factor knowledge compared those who had been diagnosed with diabetes for more than 10 years. Respondents who stayed more than 5km from the facility (aPR 1.16, 95% CI 1.04 – 1.30; p= 0.009) were more likely to have suboptimal knowledge of CVD risk factors compared to those that stayed less than 5 km from the facility.

Table 1:

Distribution of respondents by socio-demographic characteristics

Variable		Frequency (N=385)	Percentage (%)
Age	< 35 years	44	11.4
	36 – 45 years	57	14.8
	46 – 65 years	189	49.1
	> 66 years	95	24.7
Sex	Male	146	37.9
	Female	239	62.1
Education level	No/ primary education	250	64.9
	Secondary/university education	135	35.1
Residence	Rural	275	71.4
	Urban	58	15.1
	Both rural and urban	52	13.5
Average income	Less than 250,000 UGX	282	73.3
	250,000 – 500,000 UGX	66	17.1
	500,001 – 1,000,000 UGX	29	7.5
Type of diabetes	Type 2	285	74.0
	Type 1	100	26.0
Duration with diabetes	> 10 years	49	12.8
	> 5 years to 10 years	64	16.6
	> 1 year to 5 years	147	38.2
	Half a year to 1 year	86	22.3
	< half a year	39	10.1
Relative with diabetes	No	293	76.1
	Yes	92	23.9
Distance from the hospital	< 5 km	180	46.8
	≥ 5 km	205	53.2

UGX; Uganda shillings

Table 2:

Respondents’ knowledge of CVD risk factors among adult diabetic patients

Variable	Number of participants with correct responses (N = 385)	Percent (%)
A person always knows when they have heart disease	133	34.6
If you have a family history of heart disease, you are at risk of developing heart disease	171	44.4
The older a person is, the greater their risk of developing heart disease	226	58.7
Smoking is a risk factor for heart disease	329	85.5
A person who stops smoking will lower their risk of developing heart disease	234	60.8
High blood pressure is a risk factor for heart disease	277	72
Keeping blood pressure under control will reduce a person’s risk for developing heart disease	252	65.5
High cholesterol (fat) is a risk factor for developing heart disease	183	47.5
Eating fatty foods does not affect blood cholesterol levels	119	30.9
If your ‘good’ cholesterol (fat) (HDL) is high, you are at risk for heart disease	73	19
If your ‘bad’ cholesterol (fat) (LDL) is high, you are risk for heart disease	164	42.6
Being overweight increases a person’s risk for heart disease	269	69.9
Regular physical activity will lower a person’s chance of getting heart disease	300	77.9
Only exercising at a gym or in an exercise class will lower a person’s chance of developing heart disease	119	30.9
Walking and gardening are considered exercise that will help lower a person’s chance of developing heart disease	228	59.2
Diabetes is a risk factor for developing heart disease	274	71.2
High blood sugar puts a strain on the heart	139	36.1
If your blood sugar is high over several months, it can cause your cholesterol level to go up and increase the risk of heart disease	167	43.4
A person who has diabetes can reduce their risk of developing heart disease if they keep their blood sugar levels under control	231	60
People with diabetes rarely have high cholesterol	87	22.6
If a person has diabetes keeping their cholesterol under control will help to lower their chance of developing heart diseases	191	49.6
People with diabetes tend to have low HDL cholesterol (fat)	42	10.9
A person who has diabetes can reduce their risk of developing heart disease if they keep their blood pressure under control	253	65.7
A person who has diabetes can reduce their risk of developing heart disease if they keep their weight under control	289	75.1
Men with diabetes have a higher risk of heart disease than women with diabetes	96	24.9

Table 3:

Multivariate analysis of the factors associated with knowledge about cardiovascular risk factors among diabetic patients

Variable	aPR	95% CI	p-value
Sex
Male	1.00
Female	1.21	1.08 – 1.37	0.002*
Educational level
Secondary/tertiary	1.00
No formal/primary educ	1.44	1.24 – 1.66	< 0.001*
Duration with diabetes
>10 years	1.00
>5 years to 10 years	1.23	0.97 – 1.56	0.091
>1 year to 5 years	1.23	0.99 – 1.53	0.064
Half year to 1 Year	1.33	1.07 – 1.67	0.012*
< Half a year	1.47	1.15 – 1.87	0.002*
Distance from hospital
<5km	1.00
>=5km	1.16	1.04 – 1.30	0.009*

aPR: adjusted prevalence ratio, CI: Confidence Interval

Discussion

This study set out to find out the level of knowledge of CVD risk factors and factors associated with the low level of knowledge among diabetic patients attending NCD clinic at Tororo General Hospital. The study indicated 76.1% of the study respondents had suboptimal knowledge about CVD risk factors. This shows a low knowledge of the CVD risk factors among the study population. This study's findings are similar to earlier studies from Ethiopia - 70.1% (7, 10, 12–14), Tanzania - 78.8% (15) and an earlier study done in Uganda(16). However, the mean cardiovascular disease risk factors knowledge score in the current study (76.1%) is higher compared to studies in Nigeria - 48.6% (7, 10, 12–14), and India - 41% (17, 18). This could be due to the difference in population characteristics. Similarly, a study by Gladys and colleagues noted that CVD risk knowledge scores were significantly lower in African patients (8). This similarity in results among different studies confirms a widespread health literacy challenge that may be related to the developmental level of the countries in which these were conducted. This study finding provides notes that the current educational programs and materials for diabetic patients may be deficient in effectively promoting understanding of health threat that is posed by cardiovascular diseases. The study indicated that being female, less educated, newly diagnosed with diabetes and staying more than 5 km from the hospital were associated with low knowledge of cardiovascular risk factors. This mirrors that social, patient and health-facility based factors are major determinants of awareness and health behavior change. However, these findings only refer to associations, and do not imply causality. The study findings indicate that female respondents were more likely to have low knowledge about the CVD risk factors. This study finding that can be attributed to their busy schedule usually in gardens or at home according to the context in Tororo where majority are farmers. Their busy schedule could most likely be robbing them of the time required for them to follow up, understand or even remember some of these important aspects. This result contrasts Campesi and colleagues who note that women appear to be more aware of CVD risk factors than diabetic men (19). According to the authors, although women with diabetes have a higher risk of CVD than men, they appear to be more aware of CVD risk factors than diabetic men. The finding that can be attributed to differences in patient education approaches and materials used with less effective tailoring to learning styles and cultural contexts of female patients. Additionally, communication and knowledge retention around CVD may be impacted by gender imbalances in family and social support systems available to female diabetic patients. This knowledge gap has significant public health implications as women already suffer rising CVD morbidity and mortality rates globally. Poor comprehension of modifiable risk factors can directly undermine prevention and self-care among women. The difference between this studies' finding and other literatures could be due to potential sociocultural and or biological factors magnifying the risks in Tororo district. Majority of the respondents were less educated which correlated with them having lower knowledge of CVD risk factors. Individuals with lower education have been known to have lower health responsibilities and as such do not seek more information regarding their condition (11). And its management in line with the study findings, numerous studies (4, 8, 12, 13, 20) have revealed that higher education is associated with better knowledge of the CVD risk factors. The similarity noted between this study's finding and other studies done is because it aligns with multiple studies demonstrating major CVD knowledge gradients based on total years schooling among entire hypertensive and diabetic populations. Reinforcing education attainmenťs facilitative effects on retention and health behavior adoption when properly tailored. Study findings also indicate that newly diagnosed diabetic patients had low knowledge of CVD risk factors compared to those that have had diabetes for over 10 years. This suggests that the brief initial education provided to diabetic patients after diagnosis has failed in providing durable CVD insights yet their gradual acquisition through lived experiences and periodic counselling are heavily deficient in newly diagnosed patients (21). This study finding needs further exploration as other studies have indicated that the length of time a patient has had diabetes may not be linked to their knowledge of CVD risk factors (21, 22). Staying more than 5 km from the hospital has been indicated in this study to be associated with having low knowledge about CVD risk factors. This can be attributed to the fact that only Tororo general hospital that has non-communicable disease clinic and St. Anthony a private facility which are in town. This creates access barrier due to poor roads, long distances which leads to defaulting appointment and less interaction with health workers thus leading to low CVD knowledge on risk factors. This study finding is tandem with a review conducted in sub-Saharan Africa which reported that place of residence, people staying in rural areas tend to have less knowledge of CVD risk factors due to low levels of education and poverty (11). While rural-urban health divides have been explored, quantitative data specifically on gradients in CVD awareness remains relatively scarce. This study finding is similar to other literatures because it notes that there are greater patient challenges attending appointments and paying attention to CVD risk discussions when travelling farther for care (6, 8, 15). The study was limited by the fact that the heart disease fact questionnaire used in this study consisted mainly of questions that assessed knowledge by presenting a 'yes/no' type of question. Therefore, to display a superior level of knowledge, some participants might tend to reply with 'yes' to every question posed, introducing a degree of response bias. Another limitation was the involvement of a single study site.

Conclusion

This study indicates that more than three quarters of the respondents have suboptimal knowledge regarding cardiovascular disease risk factors. Lower education, residing beyond 5 km from the hospital, being female and being newly diagnosed with diabetes were associated with lower knowledge of cardiovascular disease risk factors. The study findings mirror that social, patient and health-facility based factors are major determinants of awareness and health behavior changes. This calls for capacity building among the primary care comprehensive workforce health to emphasize promotion for cardiovascular diseases to reduce disability and premature death.

What is known about this topic

• Cardiovascular diseases pose a significant health burden globally and among diabetic patients, the risk of developing CVD complications is three times higher than in non-diabetic individuals;

• In Uganda, where diabetes mellitus affects 2.7% of the population, CVDs account for 10% of premature deaths and cause substantial disability;

• Enhancing knowledge of CVD risk factors is crucial for primary prevention, but there is limited data on the diabetic patients' awareness of these risk factors, especially in primary care settings.

What this study adds

• The study provides new insights into the level of knowledge on cardiovascular risk factors among diabetic patients at Tororo General Hospital in Uganda;

• The study highlights the need for improved awareness of CVD risk factors among diabetic patients and identified that being female, having less education, being recently diagnosed with diabetes, and residing more than 5 km from the hospital contribute to suboptimal knowledge;

• The study recommends improving CVD literacy among diabetic patients through comprehensive strategies involving system protocols, workforce training, communication methods, and patient centered approaches to bridge knowledge gaps and enhance preventive measures.